The ship Captains Medical Guide is primarily intended for use on ships not carrying a doctor The ship Captains Medical Guide is primarily intended for use on ships not carrying a doctor The ship Captains Medical Guide is primarily intended for use on ships not carrying a doctor The ship Captains Medical Guide is primarily intended for use on ships not carrying a doctor
69 Cleanliness and sterilising To prevent infection in wounds, burns and other conditions, all dressings and instruments should be sterile Dressings should be supplied pre-packed and sterilised There are two ways of obtaining sterile instruments: ■ The instruments or equipment can be obtained in pre-packed sterilised containers Such instruments are for once-only use and are disposable Disposable equipment is very convenient to use ■ Instruments, which are not disposable, should be sterilised just before use in a steriliser or by boiling in water for not less than 10 minutes, then allowed to cool In using any instrument, the patient, or ‘business’, end of the instrument must not touch anything before use and only the operator should handle the operator parts of the instrument The attendant should similarly guard against infecting the wound: ■ Sleeves should be rolled-up ■ Hands, wrists and forearms should be thoroughly washed, with soap and running water ■ Surgical latex (rubber) gloves should be worn to protect both the operator and the patient General Care of wounds Classification of wounds Wounds vary enormously in extent and depth, depending on how they are caused They can be classified as follows: ■ Abrasions (Grazes) These are often superficial and if thoroughly cleaned and appropriately dressed usually heal well ■ Incised wounds These are caused by sharp implements, such as knives or glass, and may penetrate deeply to and through underlying structures, such as tendons, down to bone The wound edges are generally healthy and heal well if the edges are carefully opposed ■ Lacerations These are caused by blunt injury and involve crushing or tearing of the wound edge This results in tissue damage or loss, and consequently carries an increased risk of infection ■ Puncture Wounds These are not associated with great tissue damage or loss but carry a high risk of infection as organisms or foreign material (e.g dirt or bits of clothing) may be driven deep into the wound ■ Bites – human or animal These are often a combination of puncture and crush and carry an extremely high risk of infection, and will usually require antibiotics ■ Degloving Wounds e.g tissue being torn from a finger by a ring These injuries involve loss of blood supply to the tissue and require specialist attention Cleanliness and sterilising General care of wounds Internal injuries Head injuries Eye injuries Ear injuries Nose injuries Mouth and dental injuries Burns and scalds Dislocations Sprains and strains Care of the injured CHAPTER This chapter is about the care and treatment, after first-aid, of a casualty who has been moved to the ship’s hospital or to his own cabin, ie the definitive treatment of injuries sustained onboard 70 THE SHIP CAPTAIN’S MEDICAL GUIDE Wound Healing There are many factors that can affect how well a wound heals Factors that promote healing Factors that impede healing Clean incised wound Ragged crushed wound edges Fresh wound 12 hours old Uncontaminated Contamination No loss of tissue or blood supply Loss of tissue or blood supply Scalp/face (good blood supply) Shin (poor blood supply) Clean, incised, fresh wounds with no tissue loss and a good blood supply where the edges are held together will heal quickly and relatively painlessly They will leave a minimal scar Wounds where there is a gap between the wound edges, either because of tissue loss or because it is not possible to close the wound completely will heal by growth of new tissue This process is slow, often associated by some discharge and may be painful The resultant scar may be unsightly or disabling Treatment of Wounds Before you start: ■ Ensure the casualty is comfortable and is offered painkillers Check for damage to underlying structures If a wound is on a limb it is essential to check that structures such as major blood vessels, nerves and tendons are intact It will not be possible to repair them at this stage but such injuries should be documented and attended to at the next port Injury to a major blood vessel is usually obvious because of bleeding Apply firm pressure to the bleeding point and GET RADIO MEDICAL ADVICE DO NOT USE A TOURNIQUET! An area of numbness beyond the injury may indicate nerve injury Tendon injury will be indicated by inability to move a digit e.g extend a finger Wash your hands and prepare materials and equipment required to clean, close (stitch if necessary) and dress the wound Spread a sterile paper towel over a conveniently located table and lay out the following: ■ A sterile haemostatic clamp(e.g Spencer Wells forceps) ■ A sterile pair of scissors and a scalpel/scalpel blade ■ A pair of sterile dissecting forceps ■ Sufficient sterile gauze swabs to clean and mop the wound ■ Sterile cleaning fluid, e.g saline or antiseptic solution/wipes, in a suitable sterile container ■ Suture materials or steristrips as necessary ■ A disposable razor if necessary ■ A suitable dressing Ensure you have a container in which to place dirty or soiled dressings to hand Remember to wear surgical gloves to prevent (a) contamination of the wound and (b) exposure of yourself to the patient’s blood Preparation of the wound prior to closure If the patient is able, get them to wash the wound and surrounding area under the tap Use soap on undamaged skin Next clean the wound then surrounding area thoroughly, with sterile saline or water If the wound is heavily contaminated with foreign material (grease etc.) then an anti-septic solution, may be used If necessary use local anaesthetic to infiltrate the wound (see below) prior to gentle scrubbing with a sterile nailbrush Chapter CARE OF THE INJURED ■ Shave or clip the edges of the wound if necessary in order to see them clearly and to prevent hair being caught in the wound when it is closed Do not shave eyebrows ■ Remove any particles of dirt (wood, metal etc.) with the tissue forceps ■ Trim away any ragged edges or dead tissue with scissors or a scalpel blade, using local anaesthetic if necessary Local Anaesthetic You should decide whether a local anaesthetic (L.A.) will be required An L.A should not be necessary for the insertion of or simple stitches; indeed the application of the anaesthetic may in such cases be more painful than the suturing In more complicated cases it may be desirable to infiltrate lignocaine hydrochloride 1% Occasionally L.A is required in order to adequately clean a wound prior to closure (See MSN 1726 for dose.) Bleeding Exerting firm, sustained pressure to the wound, with a gauze swab, for five minutes or so may control bleeding If there is pulsatile bleeding, that doesn’t stop with pressure, it may be necessary to tie off a small bleeding vessel If the bleeding vessel can be seen, grasp the end with the pointed tips of the Spencer Wells forceps and make sure the bleeding is controlled Next take a length of cat-gut and, holding the forceps up, slip the ligature under the forceps and tie it off using a surgeon’s knot (see Figure 4.4) so as to encircle the end of the vessel Now cut the ligature ends short, leaving enough only to ensure that the knot doesn’t slip Then remove the forceps and inspect the wound to ensure the bleeding has ceased WARNING! If the bleeding is torrential or welling up from deep within the wound, and the bleeding point cannot be identified not grasp blindly with the forceps as you risk causing further damage Apply prolonged, firm pressure If the bleeding is still not controlled, GET RADIO MEDICAL ADVICE Wound Closure ‘God heals, we just bring the edges together.’ A plastic surgeon The purpose of closing a wound is simply to oppose the edges so healing can take place quickly b) ) Using adhesive skin closures (a) (b) SuperficialSuperficial wound ApplyApply Steristrip totoone Steristrip on side of the wound (Steristrips) In the case of superficial lacerations or incised wounds, which nevertheless need closing, it may be possible to hold the edges together using steristrips These are narrow adhesive strips Once the wound is prepared for closure the steristrips should be applied as follows: ■ Make sure the wound edges are dry or the steristrips will not stick c) (c) d) (d) ■ Stick the strip to the skin on one side of the wound up to, but not on the wound edge ■ Pull the strip across the wound so that the edges are brought together ■ Then stick the strip on the skin on the opposite side of the wound Repeat the process along the length of the wound until it is closed (Figure 4.1) Pull edges and Pulltogether edges together apply to other side Complete closure with strips as required Figure 4.1 Butterfly closures holding edges of wound together 71 72 THE SHIP CAPTAIN’S MEDICAL GUIDE Using Sutures (a) Skin Deep and gaping wounds cannot be closed effectively using Flesh steristrips alone For these wounds you will have to consider Blood whether suturing is appropriate vessel DO NOT suture if you cannot bring together not only the skin but also the deeper tissue A ‘dead space’ will become (b) infected, cause the wound to fall apart, delay recovery and may lead to the loss of the limb or even death (see Figure 4.2c) DO NOT SUTURE A WOUND THAT IS OVER HOURS OLD WHEN IN DOUBT DO NOT SUTURE Wounds A and B can be stitched The circumstances in which a suture should or should not be inserted are shown in Figure 4.2 (c) When you decide that suturing is appropriate, you will Dead require the items listed above space Sutures are supplied in sterile dry packs as a length of silk or nylon thread already attached to a surgical, curved, cutting needle These should not be opened until all is ready (d) for stitching to begin Then decide exactly what repair you intend to make If the cut is linear, for example, how many stitches will you need? If the cut is star-shaped, will one stitch to include the apices of each skin flap be adequate? Wounds C and D should not be Having decided upon the nature of the repair, open the stitched sterile pack and extract the needle with the haemostatic or Figure 4.2 needle forceps Hold the needle in the tips of the forceps approximately two- thirds the way down from its point Grasp the edge of the wound furthest from you with the One strand silk thread toothed forceps, then with a firm sharp stab drive the needle Toothed through the whole thickness of the skin at least 0.6 cm from dissecting its edge Then grasp the skin on the immediate opposite side forceps of the wound with the toothed forceps and drive the needle Spencer Wells upwards through the whole thickness of the skin so that it forceps emerges at least 0.6 cm from the wound edge (Figure 4.3) Make sure the depth of the suture is the same on both sides of the wound, or you will create a step on the surface Now cut sufficient thread off the main length to tie a surgeon’s knot with sufficient tension exerted (and no more) to bring the cut edges of the skin together If the wound is deep and Figure 4.3 Stitching a wound clean insert the needle deeply into the underlying tissue so as to draw it and the skin together Insert further stitches as required at intervals of not less than cm After tying, cut off the ends of the knots, leaving about cm of thread free to facilitate later removal of the stitches (Figure 4.3) If the cut edges of the skin tend to curve inwards into the wound, correct with toothed forceps (Figures 4.2, 4.3 and 4.5) As soon as the stitching is completed, clean the whole area with sterile saline, and apply a sterile occlusive dressing Dispose of sharps safely If you have a difficult, deep and tense wound to close use a mattress suture (Figure 4.6) A mattress suture ensures that you bring together the edges of the wound not just on the surface but throughout its depth and length Deep and gaping wounds that cannot be sutured (Figure 4.2(d)) If the wound is to be allowed to heal without suturing, lightly dress the wound with sterile paraffin gauze Then place about three layers of sterile gauze over this and make fast with bandages Re-dress the wound on alternate days until it is healed If the wound is on a limb, it should be elevated to encourage draining and reduce swelling 73 Chapter CARE OF THE INJURED Wound Infection A greater or lesser degree of infection of the wound is inevitable after injury This means that there will be a certain amount of fluid from the damaged and inflamed tissues, which should be allowed to escape Remember this when inserting stitches; not put them so close together that it is impossible for pus to discharge if it forms Also, when inspecting a wound after stitching, look closely to see if there is swelling or tension on a stitch in any part of the wound, indicating the formation of pus within the wound If there is, remove the stitch and allow free drainage of the wound This lies on one side of, and not over, the wound Figure 4.4 Surgeon’s knot Antibiotics? Consider whether antibiotic therapy is necessary Simple sutured wounds and superficial packed wounds should not require antibiotics In other cases, and especially with deep wounds involving damage to muscles, start the antibiotic treatment When in doubt, give antibiotics Stitches should be inserted by using curved ‘cutting needle’ so that each completed stitch is ‘round’ Figure 4.5 Cross section of stitched wound Begin here Tetanus Check whether the casualty has had a tetanus injection within the last 10 years If not, give 0.5ml tetanus vaccine by intra-muscular injection This injection should be noted in the casualty’s records and you should also ensure that he understands that he has been given a tetanus injection Figure 4.6 A Mattress suture Removal of stitches Once the wound has healed the stitches can be removed and a simple dressing worn until healing is complete Remember that some wounds take longer to heal than others Unless otherwise stated most sutures can be removed after one week The removal of stitches is a simple and painless operation if carried out gently Clean the area with sterile saline Grasp one of the ends of the stitch with sterile forceps and lift it up, so as to be able to insert the pointed blade of sterile scissors immediately under the knot Cut the stitch level with the skin and by gently pulling with the forceps withdraw it (Figure 4.8) Site of Wound Remove sutures after: Face 4–6 days Scalp 5–7 days Upper limbs days Lower limbs 8–10 days Back 10–12 days BA First stitch between A and B on the lip margin Figure 4.7 Stitched lip Over a joint (e.g elbow, knee) 12–14 days Figure 4.8 Removing a stitch 74 THE SHIP CAPTAIN’S MEDICAL GUIDE Internal injuries The site of each major internal organ is shown in Annex II If you suspect any organ is damaged, always start a 10 minute pulse chart so that internal bleeding can be recognised as soon as possible by a rising pulse rate If the pulse rate is or becomes high (>100 beats per minute) GET RADIO MEDICAL ADVICE Restlessness is often a sign of internal bleeding – so all patients who are restless after injury need careful watching If the patient is restless because of great pain, and other injuries permit (not head or chest injuries), give morphine This will control the pain, help to keep the patient calm and quiet, and thus diminish bleeding by rest Injury to the abdomen with protrusion of gut GET RADIO MEDICAL ADVICE This injury requires hospital treatment ashore at the earliest moment Until then, put the patient to bed lying on his back with his knees drawn up to relax the abdomen No attempt should be made to push intestines back into the abdomen Exposed intestines (gut) should be covered with a clean, non-fluffy very damp bed sheet The covering should be kept damp with cooled boiled water and should be held on loosely by a binder Alternatively the intestines could be loosely wrapped in cling-film Nothing should be given by mouth If the patient cannot be taken off the ship within about 12 hours, fluid should be given via the rectal route Keep the patient warm, give morphine to keep the patient pain-free at rest and start antibiotics until he can be taken off the ship Head injuries The majority of head injuries are not serious However, all but the most superficial head injuries are potentially dangerous Careful examination is therefore essential In the first instance, the aim of examination is to distinguish whether the patient has sustained, or is at risk of, a brain injury The characteristic sign of brain injury is alteration in the level of consciousness Assessment of the Head Injured Patient History If the patient is conscious they are usually able to tell you what happened For patients who are unconscious it is essential to get as much detail of what happened from other crew members, particularly whether the patient’s level of consciousness has changed since the injury occurred Examination There are three key indicators of brain injury ■ Level of consciousness, ■ pupil size and reaction to light, and ■ signs of paralysis down one side of the body Level of consciousness (L.O.C.) After ensuring that the casualty’s airway is clear and he is breathing adequately, your first priority is to establish the patient’s L.O.C This can be done simply and quickly using the A.V.P.U score, detailed below, or the Glasgow Coma Scale (GCS) if you are familiar with it Is the patient Alert (talking sensibly etc.)? If not does he respond to Verbal stimuli (i.e your voice)? If not does he respond to Pain (e.g Firm pressure on a fingernail with a pen)? Or is the patient Unresponsive? This is the most important indication of brain injury, and if the patient’s L.O.C is deteriorating, following a head injury GET RADIO MEDICAL ADVICE, YOUR PATIENT REQUIRES URGENT TRANSFER TO HOSPITAL 75 Chapter CARE OF THE INJURED Pupil Response ■ Are the pupils equal in size? ■ Do they constrict (get smaller) when a light is shone into them? The pupils should be the same size and constrict quickly and equally when a bright light is shone into them Some people always have unequal pupils, however, in an unconscious patient, following a significant head injury, a pupil that is widely dilated and unreactive to light probably indicates a serious, life threatening brain injury GET RADIO MEDICAL ADVICE YOUR PATIENT REQUIRES URGENT TRANSFER TO HOSPITAL Signs of Paralysis down one side of the body Is the patient moving one side of his body more than the other? You may have to inflict a painful stimulus, like pressure on a fingernail, to get an unconscious patient to move Unilateral paralysis may indicate that a blood clot is forming in the skull and putting pressure on the brain (Figure 4.9a) Under these circumstances, GET RADIO MEDICAL ADVICE YOUR PATIENT REQUIRES URGENT TRANSFER TO HOSPITAL Bloodclot exerting pressure on brain Spinal cord Care of the Unconscious Head Injured Patient It is essential that you not allow the patient to come to Figure 4.9a Compression of the any further harm brain Move the patient to a safe environment, place him in the recovery position and ensure that his airway is clear and he is breathing adequately If necessary, assisted respiration or artificial respiration should be given He must be kept constantly under observation in case he should vomit, have fits or become restless and throw himself out of the unconscious position The observation should be maintained when consciousness returns in case he lapses into coma once again Caution! Injuries to the neck are often associated with severe head injuries, so every care should be taken to minimise movement of the neck, and a neck collar, if available, should be fitted to the patient Once the patient is in a safe environment, GET RADIO MEDICAL ADVICE and continue to monitor the patients breathing pulse and level of consciousness Other Signs of Serious Head Injury Skull Fractures A skull fracture indicates that the patient has sustained a significant head injury In severe injury a depressed fracture may be apparent on careful examination There is a depression in the skull and sometimes, bony fragments may be present in the wound (Figure 4.9b) Linear fractures of the sides or top of the skull (the vault) are less obvious and normally only diagnosed on x-rays However, they are occasionally seen or felt at the base of a head wound Base of skull fractures are the result of indirect force which is transmitted to the base of the skull from a heavy blow to the vault, from blows to the face or jaw or when the casualty falls from a height and lands on his feet They can be diagnosed by deduction from the history of injury and certain examination findings CSF (cerebro-spinal fluid) leakage from the ears or nose This fluid normally circulates around the brain and spinal cord, cushioning them from injury It appears as bloodstained or sticky clear fluid that trickles from the ear or drips from the nose ‘Panda Eyes’ Bleeding from a base of skull fracture ends up appearing around both eyes giving the patient two black eyes Skin Bone Brain Figure 4.9b Depressed skull fracture with brain compression 76 THE SHIP CAPTAIN’S MEDICAL GUIDE There is little you can about the skull fracture itself If you suspect a depressed fracture, suturing any laceration should control bleeding An open wound needs to be covered to prevent infection However DO NOT poke around in scalp wounds, press over the wound, or try to remove fragments of bone from scalp wounds Using scissors, trim the hair around the wound then shave the scalp with a disposable razor so that the edges of the wound can be seen clearly Carefully clean the wound and surrounding scalp by irrigating the area with sterile saline or boiled, cooled water Dry the scalp then suture the laceration with silk, and cover this with sterile swabs before bandaging Hair should not be allowed to enter the wound Give benzyl penicillin 600 mg intramuscularly, followed by oral antibiotic treatment If the casualty is unconscious, continue to give benzyl penicillin 600 mg intramuscularly every hours If allergy develops read the section on allergy and GET RADIO MEDICAL ADVICE Fits or Convulsions Fits may occur after a head injury If the movements are violent, not attempt to restrain the casualty by the use of excessive force It is only necessary to prevent him from causing further injury to himself If the fit continues for more than a minute give diazepam 5mg rectally If this dose fails to control the fit, give a further 5mg after 3–4 minutes and GET RADIO MEDICAL ADVICE YOUR PATIENT REQUIRES URGENT TRANSFER TO HOSPITAL Headaches Headaches are common after all types of head injury, even when trivial However, they usually subside over the days following the injury A headache becomes concerning if it increases in severity and particularly if it is associated with the onset of drowsiness, confusion or vomiting Under these circumstances GET RADIO MEDICAL ADVICE Vomiting One or two episodes of vomiting following a head injury is relatively common and not cause for concern Persistent ‘effortless’ vomiting, however, may be an indication of increasing pressure within the skull caused by an enlarging blood clot When associated with increasing headache, drowsiness or confusion, this should be taken seriously and you should GET RADIO MEDICAL ADVICE Communication When communicating with a medical advisor on the ship’s radio it is essential that clear, concise information is conveyed You should report using the format in Chapter 13 including particularly: ■ A report of the patient’s ABC status A=Airway Is the patient maintaining a clear airway (Noisy breathing indicates a partially obstructed airway.) A clear airway should be maintained at all times B=Breathing Is the casualty breathing adequately? What is the respiratory rate (breaths per minute)? C=Circulation What is the pulse rate? Is the pulse full or thready? ■ A report of the patient’s level of consciousness (A.V.P.U), pupils size and reaction, and signs of paralysis This should include any change since the injury occurred ■ Details of any other injuries Longer term management of serious head injuries If a casualty with a serious head injury has to remain on board for more than a few hours, it will be necessary to monitor his condition You should record as much information as possible to help those to whom the casualty will eventually be transferred and possibly deal with certain complications Include in your records: ■ Date and time of the accident ■ How the accident happened in detail ■ The casualty’s condition when first seen Chapter CARE OF THE INJURED ■ The condition of the casualty subsequently ■ Details of the treatment you have carried out The essential observations should be recorded every half-hour while you are preparing to evacuate the casualty They are, in the order of importance: ■ The respiratory rate A clear airway should be maintained at all times If the respiratory rate drops below breaths per minute assisted or artificial ventilation should be used ■ The pulse rate ■ The level of consciousness (A.V.P.U.) ■ The state of the pupils (Size and reaction to light) ■ The development of any signs of paralysis Concussion and Minor Head injuries Concussion Concussion of the brain can occur when a heavy blow is applied to the skull It occurs because the brain is fairly soft and its function can be subject to widespread disturbance when shock waves pass through its substance Suspect this condition if the casualty loses consciousness for only a few minutes It is characterised by a loss of memory for events before or after the injury, headache and sometimes nausea and vomiting The casualty should be put to bed and allowed to rest for 48 hours Headache may be troublesome and paracetamol or codeine phosphate may be required These headaches may continue for many weeks after an accident The casualty should be warned to report immediately if he notices increasing headaches or drowsiness or if he vomits He should be sent to see a doctor at the next port Bruising Bruising will occur if a moderate force is applied Because the head is well supplied with blood, a collection of blood (haematoma) will form in the tissues under the scalp It may be sharply defined, hard and tense, or it may be a fairly diffuse soggy swelling (Figure 4.10) If the soggy area is large it may indicate an underlying fracture so the patient should be closely monitored No specific treatment is required An ice pack held over the area might control the bleeding Scalp Lacerations These are common because there is little tissue between the skull and the scalp The wound will bleed freely and often out of proportion to the size of the wound Surrounding tissues may be swollen and soggy with the blood that has leaked into them The scalp edges will be ragged, not clean-cut (Figure 4.11) Control the bleeding by pressure If necessary, stitch the wound as detailed above Ensure that you can see the wound clearly by shaving the scalp for distance of 1cm from the wound edge A Scalp Haemotoma Skull B Scalp Haemotoma Skull Figure 4.10 Bruising of the head Figure 4.11 Scalp wound Pain Relief in Head Injuries Paracetamol should be used in minor injuries for relief of headaches 1g orally every 4–6 hours (maximum 4g per 24 hours) Codeine phosphate may be used if Paracetamol is not effective 30–60mg orally or intramuscularly every 4–6 hours Morphine should not be given unless the head injury is trivial and the casualty has serious and painful major injuries elsewhere 77 78 THE SHIP CAPTAIN’S MEDICAL GUIDE Eye injuries The eye(s) can be injured in several ways which include foreign bodies, direct blow as in a fight, lacerations, chemicals and burns The eye is a very sensitive organ and any injury must be treated seriously Sciera/white of the eye Conjunctiva Upper eyelid Extraocular muscles Cornea Iris Lens Lower eyelashes Optic nerve Retina Choroid Figure 4.12 Diagram of the eye Anatomy The eyes lie partially protected in bony cavities of the skull They are guarded by the eyelids (upper and lower) which have the faculty of blinking and closure The white part of the eye is the sclera and the clear transparent central part is the cornea The cornea covers the coloured iris which controls the size of the pupil Behind the pupil, which appears black in colour, is the lens which is not normally visible The retina is the inner lining of the eyeball and it provides the sight receptors The conjunctiva is the outer lining, a thin membrane which covers both the inner surfaces of the upper and lower eyelids, and the visible part of the eyeball except for the cornea (Figure 4.12) Examination The first stage in treating an eye injury is to record a full account of the injury, what happened and the details of the symptoms It will then be necessary to carry out a careful examination It helps if the casualty is lying down, with head supported and held slightly back, during the examination Basic requirements are: ■ Good illumination (overhead light, lamp, or hand held torch or strong day light); ■ Magnifying glass; ■ Soft paper tissues; ■ Moist cotton wool swabs or moist cotton buds; ■ Fluorescein drops (stain); ■ Anaesthetic eye drops; ■ Basic antibiotic eye ointment NOTE: any opened tube should only be used for treating one patient for one course of treatment First record the general appearance of the tissues around the eye(s), looking for swelling, bruising or obvious abnormality; and then examine the affected eye(s) starting with the sclera, the conjunctiva, which covers both the sclera and the backs of the eyelids, and the cornea Comparing one eye with the other is helpful and a diagram is the best method of recording the findings 218 THE SHIP CAPTAIN’S MEDICAL GUIDE Digestive system The abdomen is a cavity shut off from the chest by the diaphragm The cavity is lined by a sheath of membrane (the peritoneum) which also enfolds some of the abdominal organs The sheath secretes fluid which keeps the abdominal contents moist and prevents friction The digestive tract This is a passage consisting of the gullet (oesophagus), the stomach, the small intestine, the large intestine, the rectum and the anus The gullet is a straight muscular tube which joins the throat to the stomach It passes down through the back of the chest cavity and goes through an opening in the diaphragm to connect with the upper part of the stomach The stomach is a J shaped pouch It enlarges when food or liquid is consumed The lower part of the stomach is narrow where it joins with the first part (duodenum) of the small intestine The small intestine is a narrow-bore coiled tube, roughly 7.5 metres long, which occupies most of the central part of the abdominal cavity The internal surface of the wall bears a large number of very small folds which project inwards to increase the surface area in contact with the contents of the intestine The small intestine joins with the large intestine in the right lower quarter of the abdomen The large intestine is a wide-bore tube, roughly 1.5 metres long, which arches upwards and across the abdominal cavity before descending the left side to join with the rectum The rectum is roughly 150 mm long and is continuous at its lower end with the very short anal canal which opens to the exterior The digestive process Digestion is the physical and chemical breakdown of food into useful products which are then absorbed by the capillaries of the blood vessels serving the gut The unwanted residue of food is excreted as faeces The digestive tract walls contain involuntary muscle which by contractions moves the contents through the entire length until they reach the rectum where they are stored as faeces prior to evacuation At certain places such as the entrance and exit to the stomach and at the anus, circular bands of muscle capable of constriction (sphincters) act as valves to shut off the flow The physical breakdown of food is accomplished by chewing, by the churning actions of the gut and by the addition of special digestive juices to the food This begins in the mouth when food is mixed with saliva which contains enzymes In the stomach, acid gastric juice is secreted by the stomach walls and acts on the food which may be retained there for several hours before passing through the duodenum Small ducts from the bile system of the liver and also from the pancreas open into the duodenum These ducts provide juices which are partly designed to neutralise the acid from the stomach juice and thus allow the enzymes secreted by the duodenal walls to act more efficiently The churning of the gut then ensures a thorough mixing of food and digestive juices throughout the length of the small intestine where most of the chemical breakdown takes place The main functions of the large intestine are to re-absorb water from the food residue and to reduce the bulk of the faeces The liver The abdominal veins drain into the liver and carry to it the useful products which have been absorbed during the digestive process One of the main liver functions is to act as a chemical factory which processes these products into substances necessary for nutrition Annex I ANATOMY AND PHYSIOLOGY Urinary system The kidneys are located at the back of the upper part of the abdominal cavity, one on each side of the spine (see Plate 14) They are embedded in fat to cushion them from injury The main kidney function is to remove water and certain harmful waste products from the blood and, by this filtering process, to form urine They control total body water and the concentration of various chemical substances in the blood The kidneys also play an important part in maintaining a steady level of blood pressure The urine is carried downward from the kidneys to the urinary bladder by tubes of small calibre (the ureters); one tube for each kidney The urinary bladder is a muscular bag situated in the front part of the cavity formed by the pelvic bones The bladder acts as a reservoir where urine collects until it is expelled by voluntary muscular contractions through a tube (the urethra) which leaves from the bladder base The male urethra measures 18 to 20 cm from the bladder to the external opening at the end of the penis A knowledge of this length is important when passing a catheter The female urethra is much shorter, being about cm in length It runs embedded in the upper vaginal wall to the external opening just above the vaginal orifice Nervous system Cerebro-spinal nervous system This consists of the brain, spinal cord and the associated nerves The brain is in the cavity of the skull It is the co-ordinating centre for the nervous system, processing incoming information from nerves concerned with sight, smell, taste, hearing, sensation etc and controlling various parts of the body, particularly muscles by way of out going (motor nerves) Higher functions include intellect, memory, personality etc The spinal cord emerges from the base of the brain and leaves the skull into the bony vertebral canal It is protected by vertebrae throughout its length, and nerves emerge at regular intervals These nerves control muscles and transmit sensation back through the spinal column to the brain Sympathetic nervous system This is a fine network of nerves not under direct voluntary control influencing the function of various organs, especially gut, bladder, blood vessels and heart Skin This protects and covers the body It consists of two layers The outer layer is hard and contains no blood vessels or nerves This outer layer protects the inner layer, where there are sensitive nerve endings numerous sweat glands and the roots of the hair Sweat consists of water, salt and some impurities from the blood The evaporation of the sweat cools the body, and helps to regulate its temperature 219 220 THE SHIP CAPTAIN’S MEDICAL GUIDE ANNEX II Anatomical drawings FRONT VIEW OF SKELETON Cranium (skull) Frontal Orbit (eye socket) Cranium Mandible (lower jaw) Orbital fossa Maxilla Clavicle (collar bone) Clavicle Head of humerus articulating with scapula (shoulder joint) Mandible Sternum Humerus (upper arm bone) Ulna (inner bone of forearm) Humerus Radius (outer bone of forearm) Carpal bones (small hand bones of wrist joint) 10 ribs joined to sternum by costal cartilage plus floating ribs not joined to sternum Metacarpal bones (long bones of the hand) Phalanges (bones of the thumb and fingers) Radius Ilium Ulna Sternum (breast bone) Pubis Hip bone Ribs Costal cartilages (non-bony attachments of ribs to the breast bone) Ischium Carpals Metacarpals Floating ribs (not attached to the breast bone) Ilium (bone of the pelvis) Phalanges Femur Ischium (bony part underlying the buttocks) Pubis (joining the two pelvis bones) Patella Head and neck of femur forming part of hip joint Femur (thigh bone) Fibula Patella (knee cap) Tibia (shin bone) Fibula Tibia Tarsal bones (small bones of the foot) Metatarsal bones (long bones of the foot) Phalanges (bones of the toes) Figure I.1 The skeleton (front) Tarsals Metatarsals Phalanges Annex II ANATOMICAL DRAWINGS BACK VIEW OF SKELETON including Parietal and occipital bones (part of cranium) Parietal bone Occipital bone Vertebral column (spinal column) Scapula (shoulder-blade) Sacrum (base of the spine) Coccyx (small bones at the base of the spine – tail bone) Scapula Os calcis (the heel) Humerus Vertebral column Radius Sacrum Ulna Coccyx Femur Fibula Tibia Os calcis Figure I.2 The skeleton (rear) 221 222 THE SHIP CAPTAIN’S MEDICAL GUIDE Masseter Strenothyroid Sternocleidomastoid Front of trapezius Deltoid Pectoralis Major Line of internal and external obliqe muscles Biceps Biceps tendon Brachials Rectus abdominis Flexors for fingers, hand and wrist Quadriceps Tibialis and peroneal muscles Ankle and foot extensors Figure II.3 Main voluntary muscles (front) Annex II ANATOMICAL DRAWINGS Deltoid Trapezius Triceps Latissimus dorsi Gluteus medius Extensors for wrist, hand and fingers Gluteus maximus Illiotibial band Hamstrings Adductor magnus Gastrocnemius/ Soleus Calcaneous (achillies) tendon Figure II.4 Main voluntary muscles (rear) 223 224 THE SHIP CAPTAIN’S MEDICAL GUIDE Larynx Gullet Thyroid gland Windpipe 2 3 Left lung Right lung 4 Heart Liver Spleen 9 Stomach Gall bladder 10 10 Large intestine Small intestine Caecum Appendix Bladder Plate 13 Organs of chest and abdomen (front) 225 Annex II ANATOMICAL DRAWINGS Left lung Spleen 1 2 3 4 5 6 7 8 Right lung 9 10 10 11 11 12 12 Liver Left kidney Right kidney Large intestine Ureter Large intestine Bladder Plate 14 Organs of chest and abdomen (rear) ABC status 76 Abdomen Examination 142 Organs 224–5 Abdominal emergencies 142–3 Abdominal pain or discomfort Appendicitis 143–4 Blast injury 40 Bleeding, internal 22 Chemicals, ingestion 46–7 Cholera 100 Colicky, causes 144–5 Cyanide poisoning 48 Enteric fever 102 Glandular fever 103 Minor abdominal conditions 137 Pelvic inflammatory disease 123 Peritonitis 150 Severe 138–9 Spasmodic 137 Yellow fever 115 Abdominal tenderness 139, 141 Abortion 140–1 Abrasions 69 Abscesses 172–3 Aching, of body generally Malaria 105–7 Poliomyelitis 110 Acquired immuno deficiency syndrome (AIDS) 124 Acute gastroenteritis 146 Acute red eye 163–4 Adhesive skin closures 71 Adrenaline 181 Aedes mosquitoes 101 Alcohol 46 abuse 64, 179–80 Allergy Lesser reactions 181 Major reaction 181 Alveoli 217 Amitriptylline 46 Ammonia vapour 48 Amoebic dysentery 59, 147 Anaemia 182 Anal discomfort fissure 143 itching (pruritus) 143 Anatomy 215–19 Drawings 220–5 Angina pectoris 128, 130–1 Animal bites 170–1 Ankle fracture 31 Anorexia nervosa 193 Ant sting 172 Anthrax 98 Antibiotic treatment Barber’s rash (sycosis barbae) 174 Boils, hand 190 Burns 82 Chest injuries 39 Diphtheria 101 Eye ointment 78–80 Face/mouth wounds 82 Hand infection 173 Impetigo 176 Internal injuries 74 Kneecap fracture 30–1 Lymphangitis 186 Open fracture, fingers 26 Paronychia 174 Rat bites 170 Wounds 73 Antihistamines, side effects 181, 184 Antiseptic 91 Anusol 143, 147 Anxiety 159 Appendicitis 138–9, 142, 173–4 Pain shifting 152 Artery 216 Artificial respiration Allergic reactions 181 Coronary thrombosis 129 Inhaled poisons 46 Lung (blast) injury 40 Overdose 47 Suffocation 18 Survivors, after hypothermia 202 Unconscious patient 15–16 Asphyxia 18 Aspirin Coronary thrombosis 129 Overdose 47 Urticaria 178 Astemizole 178 Allergic reaction 181 Asthma 54, 133–4, 181 Astringents 46 Athlete’s foot 175 A.V.P.U score 76–7 Baby Deformity or death 200 Not breathing after delivery 200 Presentation, births 200 Bacillary dysentery 147 Acute 59 Backache 94, 168–9 Dengue fever 101 Painful period 193 Plague 109 Poliomyelitis 114 Yellow fever 115 Bacteria 95 Bacterial vaginosis 122–3 Balanitis 117 Balanoposthitis 118 Bandages 7–11 Barber’s rash 174 Bed Baths 56 Feeding patients 56 Sores 57 Bee sting 172 Bell’s palsy 160 Benzoic acid 175–6 Betamethasone 191–2 Biliary colic 130–1, 138–9, 145 Bites 69 Animal 170–1 Snake 170–7 Black eye 79 Bladder/kidney inflammation 155–6 Blast injuries 39–40 Abdomen 40 Head 39 Lungs 39–40 Bleaching solutions 48 Bleeding External 20–1 Internal 22 Abdomen (blast injuries) 40 Fractures 27 High bone shaft fracture 30 Pelvis fracture 36 Severe 14 Wound 71 Bleeding peptic ulcers 151 Blisters 83 Anthrax 98 Chickenpox (varicella) 99 Blood 216 Coughing up 22 Transfusion 22 Vomiting 22 Blood pressure, high 132 Blood vessels 216 Boils 172–3 Hands/fingers 190 Bone structure 215 Boredom 94 Bovine spongiform encephalopathy (BSE) 95 Bowel movement 58 sounds 142–3 Brain 219 Compression 64 Concussion 64 Breathing difficulties 61 Breathing systems 217 Bronchi 217 Bronchitis 46, 60 Acute 134–5 Chronic 135 Measles 107 Buboes 109, 119–20, 129 Burial at sea 207 Burns Chemical 17 Eye 80 Classification 82 Electrical 17 Fluid loss 82 Heat 17 Rule of nines 82–3 Special 83 Treatment 82–3 Calamine lotion 99, 101, 107, 177 Shingles (herpes zoster) 178 Cap 195 Capillaries 216 Carbolic acid 48 Carbon dioxide poisoning 46 Carbon monoxide poisoning 46, 48 Carbonic acid gas 48 Carbuncles 172–3 Caries 165 Carrier 96 Index 227 228 THE SHIP CAPTAIN’S MEDICAL GUIDE Catering staff, personal hygiene 90 Catheterisation, male 156–8 Cellulitis 99, 172–3 Centipedes 172 Cerebro-spinal fluid, leakage 75 Chalazion 163 Chancre 120 Chancroid 117, 119–20 Chaps 175 Charcoal, oral 47 Chemical splashes 17 Chest compression 16 Allergic reaction 181 Baby not breathing after delivery 200 Coronary thrombosis 129 Chest injuries 38–9 Chest organs 224–5 Chest pain 128, 135 Associated signs 130–1 Chickenpox 99 Chilblains 175 Child inside womb 197 Childbirth 197–200 Chlamydia 117 Chlamydial lymphogranuloma 117, 121 Chlorhexidine gluconate 20% (HIBISCRUB) 189 Chlorinated lime 86–7 Chlorine 45 Compound 86 Chloroquine 106–7 Chlorpromazine 158–9 Delirium tremens 180 Choking 18 Cholecystitis 130–1, 145–6 Cholera 59, 88, 100, 146 Chostochondritis 136 Cimetidine 150 Ciprofloxacin 102 After delivery 199 Bacillary dysentery 147 Bronchitis 135 Cholecystitis 146 Genital ulcers 119 Otitis media 162 Urethritis 118 Circulatory collapse 19–20 Circulatory system 216 Cleanliness 69 On board ships 90 Clove oil 165–6 Codeine phosphate Backache 168 Boil in the ear 162 Coronary thrombosis 129 Gout 168–9 Head injury 77 Meningitis 108 Twisted testicle 154 Urticaria 178 Coil 195 Cold in the chest 134 Colds 95 Collapsed lung 137 Collar bone fracture 28 Common cold 182 Virus 85 Communicability period 96 Communicable diseases 95–115 Infectious agents 95 Management, general rules 97 Symptoms and signs 96 Terms used 96 Transmission modes 95–6 Composite temperature 94 Compression of brain 75 Compression test, pelvis fracture 36 Concussion 77 Condom 126, 195 Conjunctivitis 160, 163–4 Consciousness level 74 Constipation 204 Contact 96 Contraception 195 Contraceptive pill 195 Convulsions 19, 48 Head injury 76 Corneal abrasion 79 Coronary arteries 128 Coronary thrombosis 128–31 Crepitus 191 Cresol 48 Creutzfeld Jacob disease 95 Crush injuries 25 Hand 30 Crutch bandage 10 Curly weed rash 192 Cyanide 48 Cystitis 140–1, 155–6 Dapsone 106 Death Cause of 206 Disposal of the body 207 Mistaken 205 Procedure after 206–7 Signs 205 Dehydration 61–2 Alcoholic 179–80 Cholera 100 Survivors 204 Delirium tremens 180 Deltoid muscle, intramuscular injection 66 Dengue fever 101 Dental abscess 160 Dental injuries 81–2 Dental pain 165 Deodorant 91 Depression 158–9 Dermatitis 175, 181 Dhobie itch 175–6 Diabetes mellitus 118, 173 Treatment 182–3 Diabetic coma 64, 182–3 Diaphragm 126, 217 Diarrhoea 61, 138, 140, 142, 146 Acute gastroenteritis 146 Anthrax 98 Cholera 100 Diazepam 19, 46 Angina pectoris 128 Anxiety without depression 159 Burns 82 Hernia rupture 148 High blood pressure 132 Paroxysmal tachycardia 129 Prickly heat 177 Rectal 76 Snake bites 170 Diet, balanced see also Food 89 Diclofenac 133, 191 Rheumatic fever 169 Digestion 218 Digestive system 218 Diphtheria 101 Diseases Causes and prevention 85 Communicable 95–115 Disinfectant poisoning 48 Disinfection at the end of illness 91–2 Disinfestation 91 Dislocations 37, 84 Doctor(s) Communication 214 Ship-to-ship transfer 213 Dogger Bank itch 192 Doxycycline 100, 110, 114 Chancroid 120 Chlamydial lymphogranuloma 121 Genital ulcers 119 Granuloma inguinale 122 Pelvic inflammatory disease 123 Sinusitis 165 Syphilis 121 Twisted testicle 154 Urethritis 118 Vaginal discharge 123 Dressings Drug abuse 183–4 Drunkenness 179 Duodenal ulcer 150–1 Perforated 144 Duodenum 218 Dying, care of 205 Dysentery 90 Ear(s) Boil 162 Examination 161 Foreign bodies 81 Infection Middle 162–3 Outer 161–2 Internal 81 Parts 161 Wax 161 Ectopic pregnancy 123, 140–1, 145, 194 Eczema 181 Elbow fractures 28 Electrocution 17 Enteric fever 95, 102, 146 Epilepsy 64 Fits 19 Ergometrine 194, 198–9 Erysipelas 99 Erythromycin 114 After delivery 199 Appendicitis 144 Bronchitis 195 INDEX Chlamydial lymphogranuloma 121 Otitis media 162 Sinusitis 165 Syphilis 121 Exercise 94 Eye 163 Anatomy 78 Bandage 11 Chemical contact 47 Deep inflammation 164 Diagram 78 Examination 78–9 Fire extinguisher powder, damage 17 Injuries 78–81 Arc eyes (Welder’s flash) 80 Chemical burns 80 Corneal abrasions 79 Eyeball wounds 80 Eyelid wounds 80 Foreign bodies 79 Facial paralysis 100 Faeces Examination 58–9 Abnormalities 58–9 Certain diseases’ effects 59 Testing 195 Fainting 64 Fansidar 106–7 Female sexual organs 193 Femidom 195 Fenol oils 48 Fever 53 Anthrax 98 Chickenpox (varicella) 99 Malaria 106 Meningitis 107 Scarlet fever 112 Fibrositis 169–70 Filariasis 95 Finger Dislocation 84 Fractures 29 Infections 189–90 First aid General assessment General principles Kit 14 Priorities Fish hook, removal 192 Fish poisoning (erysipeloid) skin disease 192 Fishermen’s conjunctivitis 191 Fishermen’s tenosynovitis 191 Fits, head injury 76 see also Convulsions Flies 85 Fluconazole 118, 123 Fluid balance 61–2 Fluid retention 187 Fluids by rectum 22, 62, 150 Fluorescein 80 Food Bacteria 89–90 Canned 89 Contamination 89 Fruit 89 Poisoning 146 Vegetables 89 Foot Bandage 10 Fractures 32 Forearm fractures 29 Fractures 26–36 Circulation 27 Closed 26 Immobilisation 27 Open 26 Stress 26 Treatment General 27 Principles 26–7 Freon 49 Frostbite 94, 203 Frusemide Coronary thrombosis 129 Heart disease, oedema 187 Fungi 95 Gallstone 138–9 Colic 145 Gastric ulcer 150 Genital herpes 117, 120 itching 195 ulcers 119 warts 117, 123 Germaliods 147 German measles 103 Gingivitis 160, 165 Glandular fever 103, 167, 180 Glasgow Coma Scale 74 Glyceryl trinitrate 128 Gonorrhoea 85, 95, 117, 122 Complication 153 Gout 168–9 Gouty arthritis 168–9 Grand mal 19 Granuloma inguinale 117, 122 Grazes 69 Guardia 95 Guedel airway 63, 65, 83 Gullet 218, 224 Gum(s) ulcers 166 Haddock rash 191 Haematoma 22 Haemiplegia 160 Haemoglobin 216 Oxygen carrying capacity 217 Haemorrhoids see also Piles 58, 143, 147–8 Bleeding 148 Hand Cuts 191 Infections 173, 189–90 Tendons 189 Hand bones, fractures 29 Hangover 180 Hay fever 184 Head injuries 37 Assessment of the patient 74–5 Communication 76–7 Minor 77 229 Pain relief 77 Serious 75–6 Signs 75–6 Head and scalp bandage 11 Headache Cellulitis 173 Hangover 180 Head injuries 76 Sea sickness 188 Tension 164 Heart 216, 224 Pain 128 Heartburn 130–1, 150 Heat illness, prevention 93–4 Heel bone fracture 31 Heimlich sign (choking) 18 Helicopters 211–13 Hematoma scalp 77 Hepatitis 97, 104 B 117 Hernia Inguinal 148 Rupture 148 Strangulation 148–9, 155 Herpes zoster see Shingles 178 High-test calcium hypochlorite 87 Hip bandage 10 Hookworm 95 Hornet sting 172 Human immunodeficiency virus (HIV) 117, 124–5 Hydrocoela 154 Hydrocortisone (1%) ointment 175, 192 Hydrogen 46 Hyoscine hydrobromide 188 Hyperbaric oxygen therapy 48 Hyperpyrexia 52, 184–5 Hypertension 132 Hypothermia 17, 53, 94, 201–2 Causes 201 Diagnosis 201–2 Treatment 202 Ibuprofen 191 Immersion foot 203 Immunisation 98 Enteric fever-typhoid 102 Poliomyelitis 110 Tetanus 112 Impetigo 176 Incontinence 58 Incubation period 96 Indigestion 137 Acute 138–9 Infectious mononucleosis see Communicable diseases 103 Influenza 95, 104 Inguinal hernia 118 Inhaled poisons 45–6 Injections Filling a syringe 66–7 Intramuscular 66 Subcutaneous 66 Insecticides 91 Insulin 183 coma 182–3 Internal injuries 74 230 THE SHIP CAPTAIN’S MEDICAL GUIDE Intestinal colic 138–9, 149 Intestinal obstruction 140–1, 149 Intestine 218, 224–5 Intra-uterine (coil) device 123 Involuntary muscles 215 Isolation 92 Period 46 Jarisch-Herxheimer reaction 119, 121 Jaundice 149 Gallstone colic 145 Glandular fever 103 Hepatitis 104 Yellow fever 115 Jaw fracture 32, 81–2 Muscle spasm 92 Jellyfish 171 Jumbo wrist 191 Kidney(s) 219, 225 Stones 138–9 Kneecap Bandage 10 Fracture 30–1 Kuru 95 Labour After delivery 199 Birth 198–9 Onset 194, 198 Preparations 198 Problems during 200 Stages 197 Subsequent management 179 Lacerations 69 Laerdal Pocket Mask 46 Laryngitis 167 Laxative, after delivery 199 Legionnaires’ disease 85 Legs, fractures 32 Lice Head 177 Pubic 177 Lignocaine hydrochloride 71 Fish hook removal 192 Gel 147 Injection, pattern 171 Pulp space infection 190 Sea urchins 172 Lindane (1%) cream 124, 177 Liver 218, 224 Local anaesthetic 71 Lumbago 94 Lungs 217 Lymph node Location 186 Swelling 122 Lymphadenitis 186–7 Lymphangitis 185–6 Septic finger 190 Lymphatic inflammation 185–6 Lymphoid fever 90 Madness 158 Magnesium trisilicate compound 137, 146, 150 Malaria 85, 95, 146 Areas 105 Guidelines 106 Mosquito bites, avoidance 105 Prevention 105–6 Treatment 106–7 Malnutrition 204 Maloprim 106 Mastoid cells, infection 163 Mattress suture 72–3 Measles 95, 107, 134 Med Alert Bracelet 181 Medivac service by helicopter 211–13 Mefloquine 106–7 Melaena 58 Meningitis 107–8 Headache 163 Knee straightening test 108 Neck bending test 108 Meningococcal sepsis 97 Menstrual cycle 193 Mental illness 158–9 Serious 62–3 Metacarpal bones 29 Metazoa 95 Methyl chloride 48–9 Metronidazole Amoebic dysentery 147 Appendicitis 144 Gingivitis 166 Pelvic inflammatory infection 123 Peritonitis 150 Vaginal discharge 123, 195 Miconazole cream 176 Microbes (germs) 85 Migraine 164 Miscarriage 140–1 Inevitable 194 Threatened 194 Morning-after pill 195 Morning sickness 193 Morphine 20, 22 Anxiety relief 205 Backache 168 Biliary colic 145 Bleeding peptic ulcers 151 Contraindications Chest injury 24, 38, 40 Head injury 24, 77 Coronary thrombosis 129 Crush Injuries, hand 30 Eye, chemical contact 47 Fractures 27 Gallstone colic 145 Internal bleeding 22 Internal injuries 74 Pelvis fracture 36 Perforated ulcer 152 Renal colic 155 Retention of urine 156 Shoulder dislocation 84 Strangulated hernia 148 Thigh bone shaft fracture 30 Vaginal bleeding 194 Mouth Care 36 Injuries 81–2 Ulcers 160 Mumps 109, 118 Complications 153 Muscular rheumatism 130–1, 136, 168 Nail bed inflammation 174 Nail fold infections 190 Neck injuries 35 Neil Robertson stretcher 33, 42–4 Neomycin 191–2 Nerves 159 Nervous system 219 Nettle rash 178, 181 Neuralgia 159 Nitrazepam 46 Non-freezing cold injury 203 Nose bleeding 132 Nose injuries Foreign bodies 81 Inside 81 Nurses 51 Nursing Care of the injured 52 General 51–2 Oedema Caused by heart disease 187 Generalised 187 Localised 187 Oesophagus 218 Oil, contamination with 204 Onchcerciasis (river blindness) 95 Orchitis 109 Osteo-arthritis 170 Otitis media 161–3 Overdoses 46–7 Oxygen Coronary thrombosis 129 Haemoglobin carrying capacity 217 Pleural effusion 136 Pneumothorax 137 Requirements, head injury 37 Suffocation 18 Oxyhaemoglobin 217 Palmar space infection 190 Panda eyes 75 Paracetamol Abscesses 173 Anal fissure 143 Boils 162, 173 Bronchitis 135 Carbuncles 173 Cellulitis 99 Chostochondritis 136 Common cold 182 Dengue fever 101 Fibrositis 169–70 Glandular fever 103 Hangover 180 Head injuries 77 Influenza 104 Measles 107 Minor abdominal conditions 137 Mumps 181 Overdose 47 Painful periods 193 Pleurodynia 136 INDEX Paradoxical chest movements 39 Paraffin gauze dressing 24, 83, 174 Paralysis Aids for 57 Effects on limbs 57 Patient supported in bed 57 Signs 75 Paraphimosis 153 Paraplegia 160 Paronychia 174 Paroxysmal tachycardia 129 Pediculosis 177 Pelvic inflammatory disease 123, 124 Pelvis fracture(s) 36 Penetrating wound, chest 220 Penicillin 76 Abscesses 173 Allergy 181 Anthrax 98 Appendicitis 144 Boils 173 Carbuncles 173 Cellulitis 99, 173 Genital ulcers 119 Lymphadenitis 186 Meningitis 108 Otitis media 162 Perforated ulcer 152 Peritonitis 150 Pulp infection 174 Quinsy 168 Sinusitis 165 Skull fractures 76 Sore throat 167 Syphilis 121 Urethritis 118 Urticaria 178 Penile swelling 153 Peptic ulcer 130–1, 137, 150–1 Perforated ulcer 140–2, 151–2 Peridontal disease 166 Period problems 193 Peritoneum 218 Peritonitis 138–9, 142, 150 Peritonsinal abscess 167–8 Permethrin cream 177 Perspiration see also Sweat 93 Unseen perspiration 61 Pertusis 114 Petit mal 19 Petroleum products 48 Phenol 48 Phlebitis 133 Photophobia 108 Physiology 215–19 Pigeons (salt water boils) 186 Piles see also Haemarrhoids 58, 132, 143, 147–8 Pinworms 152–3 Pips (salt water boils) 191 Placenta 197 Delivery 199 Plague 85, 109, 109–10 Plasma 216 Loss 82 Platelet cells 216 Pleura 217 Pleural effusion 136 Pleurisy 130–1, 135 Pleurodynia 130–1, 136 Pneumonia 135 Anthrax 98 Bacteria caused 95 Influenza 104 Inhaled poisons 46 Lobar 136–7 Measles 107 Pulse rate: respiration rate 54 Sputum examination 60 Pneumothorax 130–1, 137 Poisonous fish 171 Poliomyelitis 110, 114 Port health clearance 93 Post-herpetic neuralgia 160 Post-mortem examination 207 Posthitis 117–18 Potable water 85–9 Potassium permanganate 175–6 Pre-menstrual tension 193 Pregnancy 193–4 Bleeding 194 Pressure sores 57 Prickly heat 177 Prions 95 Prochlorperasine 188 Proctitis 125 Proguanil 106 Promethazine 188 Prostate gland enlargement 156 Protozoa 95 Pruritus vulvae 195 Prussic acid 48 Pubic lice 117, 123–4 Pulmonary oedema 46, 60 Pulp infection 173–4, 190 Pulse rate Chart 55 Normal 54 Pupil response 75 Pyelitis 155–6 Pyorrhoea 166 Pyrimethamine 106 Quadriplegia 160 Quarantine period 96 Quinine 107 Quinsy 167–8 Rabies 95, 111, 170 Radio medical advice 209 Information to have ready 210–11 Rashes 97 Recovery position 181 Rectum 218 Red cells 216 Refrigerated gases, poisoning 49 Renal colic 138–9, 155 Respiration rate 54, 217 Chart 55 Normal 54 Respiratory burns 83 Restlessness 74 Rewarming 202 Frostbite 203 231 Rheumatic fever 169 Rheumatism Acute 169 Chronic 170 Muscular 169–70 Rib fractures 38, 130–1, 136 Rice water motion 59 Ring pad 11 Ringworm 85, 95, 176 Roundworms 153 Rubella 103 Salbutamol inhaler 134 Salpingitis 123, 140–1, 145 Salt water boils 191 Scabies 117, 124, 178 Scalds see also burns 17 Scalp lacerations 77 Scarlet fever 97, 112 Sciatica 94, 160, 168 Scorpions 172 Scrotum swelling 118, 154–5 Sea sickness 188 Sea urchins 172 Sensation, absence 33 Septicaemia 107–8 Sexually transmitted disease 117–26 Instructions Medical attendants 125 Patients 125–6 Prevention 126 Treatment centre at ports 125 Vaginal discharge 194–5 Shakes, alcohol withdrawal 180 Shingles 130–1, 136, 178 Ship-to-ship transfer 213 Shock Abdominal wounds 24 Causes 19 Signs 19 Symptoms 19 Treatment 20 Shoulder Blade fracture 28 Dislocation 84 Fractures 28 Sick quarters 51 Sinusitis 165 Frontal 165 Maxillary 165 Skeleton 220–1 Skin 219 chemical contact 47 Skull fractures 75–6 Sleeping tablets, overdose 46 Slings 12–13, 28 Slipped disk 94 Snake bites 170–1 Sodium bicarbonate, stings 172 Sodium chloride Acute gastroenteritis 146 Bacillary dysentery 146 Sodium hypochlorite solution 48, 87 Solvents 48 Sore throat 167 Spencer Wells forceps 70–2 Spiders 172 232 THE SHIP CAPTAIN’S MEDICAL GUIDE Spinal cord 219 Injury 160 Spine fractures 33–5 Splints 13–14 Inflatable 14 Sprains 84 Sputum, examination 60 Stab wounds 25–6 Abdomen 26 Chest 25 Limbs 26 Sterilisation 69, 91 Steristrips 70–1 Stings 171–2 Stomach ulcer 150–1 Stove-in chest injury 38–9 Stretcher see Neil Robertson stretcher Strains 84 Strangulated hernia 140–1 Strangulation 18 Stroke 64, 132, 160 Headache 164 Styes 163 Suffocation 18, 134 Carbon dioxide 48 Suicide, potential 159 Sunburn 83, 94 Surgeon’s knot 72–3 Survivors 201–4 Sutures 72 Swallowed poisons 46–7 Sweat see also Perspiration 219 Swollen legs 204 Sycosis barbae 174 Sympathetic nervous system 219 Syphilis 85, 117, 120–1 Tapeworm 95 Temazepam 46 Temperature Chart 55 During cold water emersion 201 High Delirium tremens 180 Malaria 106 Treatment 185 Typhoid 102 Typhus fever 114 Yellow fever 115 Normal 53 Rectal 53 Taking 53 Tendon injuries 191 Tepid sponging 185 Testicle(s) Injury 154 Pain 153–4 Torsion 118, 153–4 Tetanus 73 Lockjaw 112 Protection 180 Tetracycline ointment (1%) 118 Thigh bone shaft fractures 30 Threadworms 152–3 Thrush 195 Tic Douloureux 159 Tinea 176 Tinea pedis (athlete’s foot) 95 Tingling 33 Tit juice conjunctivitis 191 Tonsillitis 167 Toothache 165–6 Toxic hazards 45 Transient ischaemic attack (TIA) 160 Transport of casualties 40–4 Triangular sling 12–13, 28 Trichlorethylene (trilene, trike) 49 Trichomoniasis 122–3 Trigeminal neuralgia 159 Trike see Trichlorethylene 49 Trilene 49 Trimethoprim Bronchitis 135 Cystitis 156 Pyelitis 156 Tubal infection 145 Tubal pregnancy see also Ectopic pregnancy 145 Tuberculosis 95, 113 Typhoic fever 85 Typhoid 59, 102 Typhus fever 114 Ulcers 150–2 Umbilical cord, tie and cut 199 Unconscious patient Chest injuries 39 Choking 18 General management 65 Head injury, care of 75 Moving 44 MUSTS 63 Treatment 15–16 Unconsciousness, diagnosis 64 Upper arm fractures 28 Upper eyelid eversion 79 Urethra 219 Urethral discharge 117–18 Urethritis 117–18 Complications 153 Urinary infection 144 Urinary system 219, 224–5 Urination difficulty 204 Urine 219 Blood-stained 36 Examination 143 Retention 156–8 Testing 59–60 Glucose 173, 195 Protein 132, 187 Urticaria 178, 181 Vaginal bleeding 196 Vaginal candidiasis 122 Vaginal discharge 122–3, 123, 194–5 Valium 46 Varicella 95, 97, 99 Varicose ulcer 133 Varicose veins 132 Vein 216 Venom, sucking 171 Ventilation 93 Viruses 95 Visual disturbances 132 Migraine 164 Voluntary muscles 215 Front 222 Rear 223 Vomited matter, examination of 60 Vomiting Cholecystitis 145–6 Cholera 100 Coronary thrombosis 128–9 Dehydration 61 Drunkenness 179 Head injury 76 Inhalation 179 Lifeboat, in 204 Meningitis 107–8 Migraine 164 Peritonitis 150 Pregnancy induced 193 Sea sickness 188 Severe abdominal pain 138–41 Snake bites 171 Wasp sting 172 Water, fresh Distribution system by superchlorination 86 Hoses 87–8 Taking water on board 88 Treatment by chlorine 88–9 Storage tanks 85–6 Disinfection 86 Water retention see also Oedema 132 Welder’s flash 80 White cells 216 Whitlows 172, 174 Whooping cough 114 Wind 137 Worms 59, 152–3 Wound(s) Abdominal 24 Bullet 23 Chest 24 Classification 69 Face and jaw 25 Head 24 Healing 70 Infection 73 Metal fragments 23 Palm 25 Stitches, removal of 73 Treatment 70–3 Wrist fractures 28 Yellow fever 85, 115 Zinc oxide Ointment 143, 175 Powder 166 Index by Dr Olivera Potparic ...70 THE SHIP CAPTAIN S MEDICAL GUIDE Wound Healing There are many factors that can affect how well a wound heals Factors... required Figure 4.1 Butterfly closures holding edges of wound together 71 72 THE SHIP CAPTAIN S MEDICAL GUIDE Using Sutures (a) Skin Deep and gaping wounds cannot be closed effectively using... lip Over a joint (e.g elbow, knee) 12–14 days Figure 4.8 Removing a stitch 74 THE SHIP CAPTAIN S MEDICAL GUIDE Internal injuries The site of each major internal organ is shown in Annex II If you